Clinical aspects of cleft palate repair

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Clinical aspects of cleft palate repair

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Clinical aspects of cleft palate repair

  1. 1. Clinical Aspects of Cleft Palate Repair Ahmed Atef, Msc, MRCS Specialist of plastic surgery Mataria Teaching Hospital
  2. 2. Objective • • • • • • • Incidence Surgical Anatomy Embryology Classification / Cleft Variants Clinical Effects Management Future
  3. 3. Cleft Palate / Cleft lip is the the most common craniofacial malformation Second most common congenital defect
  4. 4. Isolated Cleft palate • No racial variation • 1:2000 live birth • M:F = 1:2 • Left : Right : B/L = 6:3:1
  5. 5. Surgical Anatomy The palate forms a dynamic boundary between the oral cavity and the nasal cavity. It is composed of the hard palate anteriorly and the soft palate posteriorly.
  6. 6. Surgical Anatomy Normal Palate • Primary Palate • Secondary Palate Hard Palate Soft Palate
  7. 7. Surgical Anatomy The hard palate includes the palatal processes of the maxilla and the horizontal plate of the palatine bone with adherent mucoperiosteum (attached to bone by Sharpey’s fibres).
  8. 8. Surgical Anatomy Three pairs of foramina mark the surface of the bony palate • Incisive Foramen • Greater Palatine Foramen • Lesser Palatine Foramen
  9. 9. The soft palate is a dynamic structure that acts as a valve between the oropharynx and nasopharynx. An intact and functioning soft palate is essential for normal speech and feeding.
  10. 10. Surgical Anatomy Soft palate • Mucosa • Five paired muscles & central aponeurosis Tensor veli palatini Levator veli palatini Palatoglossus Palatopharyngrus Uvualis *Veli (Latin) means curtain
  11. 11. Surgical Anatomy Tensor palati Origin: scaphoid fossa of the medial pterygoid plate, the lateral part of the cartilaginous auditory tube then passes around the pterygoid hamulus as a tendon Insertion: broad triangular tendon at the posterior aspect of the hard palate as part of the palatine aponeurosis Action: tense the soft palate to form a platform that the other muscles may elevate or depress.
  12. 12. Surgical Anatomy Levator palati Origin: petrous bone and the medial part of the auditory tube Insertion: middle third of upper surface of the soft palate at upper surface of the palatine aponeurosis as far as the midline
  13. 13. Surgical Anatomy Levator palati The paired muscles form a ‘V’-shaped sling pulling the soft palate upwards and backwards to close the nasopharynx.
  14. 14. Surgical Anatomy Palatoglossus Origin: Palatine aponeurosis Insertion: Side of tongue Action: Pulls root of tongue upward and backward, narrows transverse diameter of oropharynx
  15. 15. Surgical Anatomy Palatopharyngeus Origin: Palatine aponeurosis Insertion: Posterior border of thyroid cartilage Action: Elevates wall of pharynx, pulls palatopharyngeal folds medially
  16. 16. Surgical Anatomy Musculus uvulae Origin: Posterior border of hard palate Insertion: Mucous membrane of uvula Action: Elevates uvula
  17. 17. Surgical Anatomy The soft palate is raised by the contraction of the levator palati. At the same time, the upper fibers of the superior constrictor muscle pull the posterior pharyngeal wall forward. The palatopharyngeus muscles contract to pull palatopharyngeal arches medially, like side curtains.
  18. 18. Surgical Anatomy By this means The intact palate can periodically, selectively, an d completely isolate the nasopharynx from the oropharynx during Feeding & Speech
  19. 19. Surgical Anatomy This harmony in muscular action is necessary for Velopharyngeal Competence
  20. 20. Surgical Anatomy
  21. 21. Surgical Anatomy
  22. 22. Embryology Development of the face begins in the fourth week in utero, when neural cells migrate and fuse with mesodermal elements to form the facial primordium.
  23. 23. Embryology It results from the fusion – Two mandibular processes – One frontonasal process – Two maxillary processes
  24. 24. Embryology The palate develops between the 5th and the 12th week CRITICAL period of palatal development is between the 6th and the 9th week. Soft palate development is completed at 12th week
  25. 25. Embryology Primary palate : Median palatine process from the medial nasal prominences. Secondary palate : Lateral palatine process from the maxillary prominence
  26. 26. Embryology 6th – 9th week: Initially, the palatine processes are oriented vertically on either side of the developing tongue. The tongue is displaced inferiorly as the head grows and the neck straightens, the lateral palatine processes are elevated and grow medially to fuse with the septum
  27. 27. Embryology Is Cleft a Deficiency?
  28. 28. Embryology Interference with fusion results in Cleft Three theories: i) Failure of fusion of the lateral shelves ii) Failure of mesodermal penetration of the shelves: iii) Mechanical interference (the tongue) such as in Pierre Robbin Sequence
  29. 29. Embryology Gato et al. 2002, expression of chondroitin sulfate proteoglycan is important in palatal shelf adhesion and is supposed to be regulated by TGF-b3 Gato A, Martinez ML, Tudela C, Alonso I, Moro JA, Formoso MA, Ferguson MWJ, Martinez-lvarez C (2002) TGF-b3-induced chrondroitin sulphate proteoglycan mediates palatal shelf adhesion. Bush et al. 2003; Herr et al. 2003, Expression of T box transcription factor Tbx22 is found in the inferior nasal septum and the palatal shelf before fusion. Bush JO, Lan Y, Maltby KM, Jiang R (2002) Isolation and developmental expression analysis of Tbx22, the mouse homolog of the human x-linked cleft palate gene. Dev Dyn 225: 322-326 Herr A, Meunier D, Mller I, Rump A, Fundele R, Ropers H-H, Nuber UA (2003) Expression of mouse Tbx22 supports its role in palatogenesis and glossogenesis. Dev Dyn 226:579–586
  30. 30. Classification Veau Classification 1931 Veau Class I: isolated soft palate cleft Veau Class II: isolated hard and soft palate Veau Class III: unilateral CLAP Veau Class IV: bilateral CLAP
  31. 31. Classification Striped Y by Kernahan 1971 Millard modification
  32. 32. Cleft Variant
  33. 33. Cleft Variant
  34. 34. Cleft Variant
  35. 35. Cleft Variant
  36. 36. Syndromatic Cleft Treacher-Collins syndrome
  37. 37. Syndromatic Cleft Pierre Robin syndrome
  38. 38. Syndromatic Cleft Van der Woude’s syndrome
  39. 39. Clinical effects Patients with cleft deformities experience a multitude of problems including • • • • Feeding problems Speech difficulties Otologic issues Midface growth impairment.
  40. 40. Clinical effects Feeding The infant is usually not able to suck efficiently due to inability to achieve negative pressure. Nasal regurgitation. Feeding regimen: includes the use of squeeze bottles and holding in a nearly sitting position during feeding
  41. 41. Clinical effects Speech Patients are unable to produce high intra-oral pressure. Normal velopharyngeal closure is crucial for production of intelligible speech; any abnormalities in this mechanism can result in hypernasality, nasal emissions, imprecise production of consonants.
  42. 42. Hearing Serous otitis media. Abnormality of LVP which aids the TVP to dilate ET. Nasal regurgitation. Treatment with myringotomy tubes is required pre- and postcleft repair.
  43. 43. Management requires a multidisciplinary approach spanning multiple specialties • Plastic surgery • Speech pathology • Otolaryngology • Genetics • Pediatrics • Orthodontics • Audiology
  44. 44. Goal Restoring the morphologic form & function Production of a competent velopharyngeal sphincter
  45. 45. Principles • • • • • Closure of the defect Correction of the abnormally inserted muscles Reconstruction of the palatine sling Tension free repair 2 layer repair of the hard palate & 3 layer repair of the soft palate
  46. 46. Von Langenbeck 1861 pioneered the first bipedicle mucoperiosteal flaps and relaxing incisions for palate closure surgery in one stage. Langenbeck v, B. Uranoplasty by means of raising mucoperiosteal flaps. Arch klin chir. 1861;2:205
  47. 47. Veau 1931, The vomer flap and suturing of velar muscles aiming at lengthening the palate
  48. 48. Wardill and Kilner 1937, “pushback” theory V-Y retro positioning of the palate increases the length further. By connecting the lateral incisions to the incisions made for the nasal turn in flaps. Wardill WEM. The technique of operation for cleft palate. Br J Surg. 1937;25: 117-130
  49. 49. A different approach was described by Furlow 1986 with the double-opposing z-plasty without relaxing incisions Furlow LT, Jr. Cleft palate repair by double opposing Z-plasty. Plastic and reconstructive surgery. 1986;78:724-738
  50. 50. The Bardach 1991 two-flap palatoplasty uses two large fullthickness hard palate flaps that are mobilized and closed anteriorly and medially without pushback Bardach, J. and P. Nosal: Geometry of the two-flap palatoplasty. (2nd). St. Louis, Mosby-Year Book, 1991
  51. 51. Rohrich et al., 2000 & Sommerlad et al., 2002 Closure of the palate can be performed in two stages. This closing the soft palate early, between 3 and 6 months involves of age, and delaying the repair of the hard palate. Sommerlad BC, Mehendale FV, Birch MJ, Sell D, Hattee C, Harland K. Palate rerepair revisited. Cleft Palate Craniofac J. 2002;39:295-307. To limit the effect of the hard palate repair on maxillary growth. It is suggested that the subperiosteal scarring impairs midfacial growth.
  52. 52. Preoperative considerations • Age: 9-12 month • Associated anomalies • Routine Lab. Investigations • Booking a unit of packed RBCs after G/XM • Otologic and audiologic assessment
  53. 53. Operative preparations i) RAE tube ii) Dingman iii) Shoulder roll iv) Head Donut v) Local anesthetic with 1:200,000 epi vi) Position: supine, neck Extended, reverse trendlenberg vii) Throat pack
  54. 54. Operative preparations
  55. 55. Steps i) Inject 1 :200 000 epinepherine into the palate. ii) Don't inject in areas sutures will be placed iii) Wait 7 minutes for the epinephrine to take effect iv) Make incision along the medial side of the cleft v) Make releasing incision to get to bone on both sides vi) Use freer to elevate mucoperiosteal flap vii) Dissect nasal mucosa vii) Strip LVP muscle off abnormal insertion & create palatine sling viii) Three layer repair
  56. 56. Steps
  57. 57. Vomerian flap
  58. 58. Postoperative care • • • • • Keep your eye on the airway AB Analgesic Feeding: fluids, soft diet, no bottles for 3w Arm restraints
  59. 59. Complications Early: Haemorrhage Airway obstruction Dehiscence Fistula Late: Bifid uvula VPI Maxillary hypoplasia Dental malalignment
  60. 60. Tissue engineering advancements over the last decade has provided a plethora of materials that may be suitable for the healing of craniofacial defects like the cleft palate. Future directions with regards to the use of stem cells especially ASCs in craniofacial repair are discussed, including possible scaffold for reconstruction of palatal defect
  61. 61. Quiz Embryogenesis of primary & secondary palate? Muscles of soft palate? Velopharyngeal mech? Clinical effects? Preoperative preparations? Principles of repair? Postoperative care?

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